Misplaced subclavian central venous catheter

Percutaneous Central Venous Catheter (CVC) insertion using internal jugular and Subclavian veins routes is common procedure for all intensive care admitted patients and some patients in the ward as demand arises in central and referral hospitals of Botswana. This is a case report of a patient on whom a third attempt of re-inserting a CVC for fluid and total parenteral nutrition (TPN) was made. X-ray showed that left Subclavian inserted catheter was mis-directed to internal jugular vein of the same side creating discomfort to the patient. Ultra sound is recommended for routine investigation to confirm proper Central venous catheter placement as it can reduce failure, minimize complication and reduce cost of treatment.


Introduction
This case presentation was an accidental finding of Misplaced CVC in a tertiary teaching hospital of Botswana. The hospital has a capacity of total of 500 beds for admission and with this there is 8 bedded multy disciplinary Intensive Care Unit (ICU) for intensive care service. The ICU accepts all patients from all the specialties except neonates as there is a neonatal ICU separately managed by paediatric intensive care specialists. The intensive care service is done by Anaesthesiologists and intensive care specialists whom are called to the wards to insert CVC as the need arises. Percutaneous

Patient and observation
Our patient is a middle age woman diagnosed with intestinal obstruction, HIV positive on HAART had undergone surgery where resection of more than a meter small intestine was done. Five days post-surgery, she needed to have total parenteral nutritional therapy. Right side Internal Jugular vein was accessed, the CVC stayed only 2 days and then blocked. The second insertion of the CVC was done by another Anaesthesiologist using the right subclavian infraclavicular approach but soon was seen that this CVC was infiltrating and creating swelling around the insertion site. The third trial was done by a third Anaesthesiologist who was on call on that night and he inserted the CVC in the left Subclavian, infra clavicular approach at surgical ward. At time of insertion of the J guide wire the patient complained neck and ear pain at the side of catheter insertion for that the wire was removed and re-tried on the same spot. Catheter placement confirmed by drawing blood, putting the fluid bag below the heart level and back flow of venous non pulsating blood was observed, fluid flow initiated with room temperature normal saline but the patient still continued to complain discomfort at around the ear of the same side of insertion.
Since the placement was sure but patient had pain with the flow of fluid, X-ray was ordered and result showed that the catheter was misplaced to the left internal Jugular vein and was found to be deep proximal to these valves will lead to inaccurate CVP monitoring or potential irritation of the valve area by the catheter or infused fluids [1,2]. Xiaoyan Gu and colleagues reported a case in which a CVC was inadvertently directly inserted into the right main pulmonary artery, and its malposition was detected by transesophageal Page number not for citation purposes 3 echocardiography (TEE) [2]. Positioning of the tip of the catheter in unintended place is relatively common estimated to be 5.4% from SCV to the IJV, no difference whether insertion is in the right or left side [3]. placement of CVC by using Ultrasound, ECG guidance, real-time Xray imaging, and other aids [11]. This finding by itself showed that there is a need of assessment of inserted CVC catheter is necessary and US is a mobile instrument that can be used immediately after the insertion and it can reduce the exposure to radiation,. On a discussion of pro and cons of UG-CVC insertion by John G.T.
Augoustides and colleagues noted that the advent of UG-CVC significantly improved vein localization, cannulation success, and freedom from complications. It was also noted that it is cost effective even though it demands training of personnel and purchasing of equipment [12,13]. In a recent expert recommendation on safety practices for vascular access. UG-CVC has already been proposed as a standard of care by national medical agencies such as the IOM, AHRQ, and NICE for more than 5 years [13]. In our hospital X-ray examination is used to confirm CVC placement but all patients are not examined after insertion of Catheter. Our case report showed that the left side inserted subclavian catheter unintentionally has been directed itself in the left internal Jugular vein and has created discomfort repeatedly.
This could have been detected by routine use of X-Ray and preferably ultrasound after CVC insertion.

Conclusion
This case shows that there is a risk of failure to pick misplacement of CVC. We recommend routine use of ultra sound guided insertion of CVC and training of Ultra sound guided insertion of CVC. Even though further study is required, it is obvious that use of ultra sound will reduce failure, Complications, outcome and cost of treatment of patient.